Tobacco use is currently the leading cause of death in the United States. Those who smoke tobacco also report higher levels of depression than nonsmokers. For U.S. women, the prevalence of smoking is 14.8 percent, and quit rates are poorer than those of men. Depression also is more common among women who smoke, and those displaying more symptoms of depression don't fare as well in smoking treatment.

There have been very few studies looking at smokers with depression, and just one of those focused on women. In fact, women with depression who smoke are considered a tobacco use disparity group and a pressing public health issue, according to Christi A. Patten, Ph.D., a tobacco cessation researcher at Mayo Clinic's campus in Minnesota and study author.

Women with depression, therefore, are in need of smoking interventions. Having looked at smoking and depression for some time, Dr. Patten and colleagues launched a pilot study investigating the effect of vigorous, supervised exercise for smoking cessation in these women, enrolling 30 adult female smokers with moderate to severe depression.

Participants were randomly assigned to 12 weeks of in-person, vigorous, supervised exercise at a local YMCA three times a week for 30- to 40-minute sessions or health education. All of the women underwent nicotine patch therapy as well as behavioral counseling for smoking cessation. The investigators assessed all participants at baseline, at 12 weeks, and then at six months after their target quit dates.

Additionally, as heightened inflammation is associated with elevated distress levels — indicating unregulated emotion — Dr. Patten and colleagues assessed biomarkers of inflammation. Participants provided blood samples at the study's outset and again at the end of week 12. The research team assessed these samples for potential differences between the two treatment groups, as well as those who did not cease smoking and those who were abstinent by the study's end.

The study's design was unique in its use of more-vigorous, intense exercise, which was innovative due to uncertainty about adherence for the exercise regimen due to the participants' depression.

Findings

Percentage of patients abstinent at the end of 12 weeks' treatment and 6 months' follow-up

Percentage of patients abstinent at the end of 12 weeks' treatment and 6 months' follow-up

Percentage of patients with biochemically confirmed, seven-day point prevalence smoking abstinence at the end of 12 weeks of treatment and six months follow-up by treatment group. Reprinted with permission from Nicotine and Tobacco Research.

Happily for the investigators, "the study participants did quite well," says Dr. Patten. "We had good adherence rates — the women showed up."

Dr. Patten and team found treatment adherence high for both groups: participants randomized to the exercise regimen attended an average of 72 percent of their sessions, and those randomized to health education attended an average of 66 percent. The exercisers had a higher smoking abstinence rate at week 12 than those given health education, yet there were no significant differences in smoking cessation rates at six-month follow-up.

Laboratory analysis revealed an increase in proinflammatory cytokine interleukin-6 for women who smoked compared with those who were abstinent at week 12.

These findings appeared in the Jan. 1, 2017, issue of Nicotine and Tobacco Research.

Conclusions and implications for practice

This pilot study indicates that supervised exercise is effective, at least for the short term, for women with depression who smoke, according to Dr. Patten. However, the long-term adherence was limited, as participants dropped off sharply in their attendance at the exercise facility after study's end: only two of the women returned after week 12.

"They weren't keeping up as much without a supportive coach," she says. "We think that people with depression need more support and structure. Actually, smokers in general do. It seems that adding that supervision is the key to exercise adherence."

Dr. Patten adds that conducting this study in a community setting gives the program additional reach and makes it more replicable. She emphasizes that providing some structure and support for women with depression who smoke to complete an exercise regimen is key. "You can't just give them a piece of paper with guidelines," she says.

If patients express willingness to engage in exercise, treating physicians could connect them to a fitness center. Gym trainers or even technology could serve in a supervisory role for smokers with depression to support them in adhering to an exercise regimen, Dr. Patten indicates. Physicians also may play a role in encouraging patients to exercise with a friend or partner and then following up with them to ensure compliance.

Future study plans

Dr. Patten and colleagues are planning a more definitive study of exercise for smokers with depression in which they will be looking to enroll racially diverse men and women with a greater range of depressive symptoms.

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